A few months after completing what he believed was a reassuring annual health check-up, a 52-year-old corporate executive arrived in the emergency department with severe chest pain. His medical records showed nothing particularly alarming. His blood pressure was under control. He exercised occasionally. Most importantly, his treadmill test, conducted as part of a routine executive health package, was reported as normal.
Within hours, doctors confirmed that he was having a heart attack.
The question seemed obvious: How could a man with a normal treadmill test suffer a major cardiac event only weeks later?
For Dr. Babu Ezhumalai, Senior Consultant in Interventional Cardiology, Structural and Endovascular Interventions at MGM Healthcare in Chennai, the case reflects a recurring pattern he has observed throughout his career. "Many people assume that a normal treadmill test means they do not have heart disease," he says. "Unfortunately, that is not always true."
As India confronts one of the world's fastest-growing burdens of cardiovascular disease, Dr. Ezhumalai is among a growing number of cardiologists advocating a more nuanced understanding of cardiac risk…one that goes beyond a single test result and focuses on identifying disease before it becomes life-threatening.
India at Risk
Cardiovascular disease remains one of the leading causes of death in India. What worries cardiologists even more is the age at which the disease increasingly appears.
Unlike many Western countries, where coronary artery disease often manifests later in life, Indians frequently develop significant cardiovascular disease during their forties and fifties. Diabetes, obesity, hypertension, smoking, sedentary lifestyles, metabolic syndrome and genetic predisposition have combined to create what many experts describe as a perfect storm. For physicians working on the front lines, this reality has transformed the practice of preventive cardiology.
Dr. Ezhumalai's work spans interventional cardiology, structural heart disease and endovascular interventions. Much of his practice involves treating patients whose disease has already progressed to a stage requiring complex procedures. Yet some of the cases that have left the strongest impression on him involve patients who believed they were healthy.
"They often did everything they thought they were supposed to do," he says. "They had annual check-ups, underwent investigations, and received reassurance. Then they experienced a cardiac event that seemed completely unexpected."
The problem, he argues, is not that testing was performed incorrectly, but that many people misunderstand what certain investigations are designed to detect.
India and the Treadmill Test
For decades, the treadmill test (TMT) has occupied a central place in preventive health screening across India. The procedure features in executive health packages, corporate wellness programmes and annual preventive check-ups. For many Indians, a normal treadmill report meant a healthy heart.
The TMT measures how the heart responds to increasing physical exertion by monitoring electrocardiographic changes while a patient walks or runs on a treadmill. It remains an important diagnostic tool and evaluates exercise tolerance, functional capacity and whether blood flow to the heart becomes insufficient during exercise.
However, according to Dr. Ezhumalai, its role is often misunderstood. "The treadmill test evaluates the physiological response of the heart during exercise," he explains. "It does not directly visualise the coronary arteries."
That distinction, he says, has important clinical implications.
Beyond Symptoms
One of the most significant changes in cardiovascular medicine has been the shift from identifying disease after symptoms appear to identifying disease before symptoms develop. Dr. Ezhumalai believes physicians increasingly need to ask not only whether a patient has symptoms but also whether their overall cardiovascular risk justifies further evaluation.
"Modern preventive cardiology is not about scanning everyone," he says. "It is about identifying the right investigation for the right patient at the right time."
He believes additional anatomical imaging should be considered selectively in patients whose risk profiles suggest silent coronary artery disease despite reassuring treadmill findings.
These include individuals with longstanding diabetes, multiple cardiovascular risk factors, chronic smoking, hypertension, obesity, metabolic syndrome, elevated Lipoprotein(a), a strong family history of premature coronary artery disease, persistent chest discomfort despite a normal treadmill test or when the clinical picture simply does not match the investigation. "The patient is always more important than the test," Dr. Ezhumalai says.
The Case That Changed the Conversation
One patient remains particularly memorable for Dr. Ezhumalai. The 52-year-old corporate executive had undergone a routine executive health check-up. His treadmill test was completely normal and he had been reassured that his heart was healthy. Yet he continued to experience vague chest discomfort.
"What concerned me was not the treadmill report but his overall risk profile," Dr. Ezhumalai recalls. The patient had longstanding diabetes, hypertension, abdominal obesity and a strong family history of premature coronary artery disease. "The clinical picture simply did not fit with the reassuring treadmill findings," he added.
A CT Coronary Angiography was performed and it revealed significant multivessel coronary artery disease. Subsequent invasive coronary angiography confirmed severe disease requiring revascularisation.
The case reinforced an increasingly recognised principle in cardiology. A treadmill test evaluates the consequences of coronary artery disease. A CT Coronary Angiography visualises the disease itself.
The Unnoticed Signs
For many years, heart disease was viewed primarily as arteries gradually becoming narrower until blood flow was critically restricted but modern cardiology tells a more complex story.
Many heart attacks arise from relatively small plaques that narrow an artery by only 30 to 50 per cent. These plaques may not reduce blood flow sufficiently to produce abnormalities during a treadmill test. What makes them dangerous is not necessarily their size but their biological behaviour.
"A vulnerable plaque may have a large lipid core, intense inflammation and a thin fibrous cap," Dr. Ezhumalai explains. "These plaques are prone to rupture." Once rupture occurs, a blood clot forms rapidly and may completely block the artery, resulting in an acute heart attack.
Advances in imaging are helping cardiologists identify these lesions more accurately. While CT Coronary Angiography can identify high-risk plaque characteristics non-invasively, invasive imaging techniques such as Optical Coherence Tomography (OCT) and Near-Infrared Spectroscopy (NIRS) provide detailed information about plaque composition, including lipid-rich vulnerable plaques that may otherwise remain undetected.
This evolving understanding, he says, represents one of the biggest shifts in cardiovascular medicine. "The problem is not merely the size of the blockage. It is the biological behaviour of the plaque," says Dr. Ezhumalai
Coronary Calcium Scoring
Among the technologies gaining prominence is Coronary Artery Calcium (CAC) scoring. Unlike treadmill testing, which measures cardiac performance during stress, calcium scoring estimates the burden of atherosclerosis itself. The examination uses a specialised CT scan to detect calcium deposits within the coronary arteries.
For many patients, a calcium score of zero provides considerable reassurance, while increasing calcium burden identifies individuals who may benefit from earlier preventive intervention. "Calcium scoring allows us to look for evidence of disease itself," says Dr. Ezhumalai. "That is very different from evaluating exercise performance."
The test is quick, non-invasive and does not require contrast injections, making it particularly useful in selected asymptomatic individuals whose long-term cardiovascular risk remains uncertain.
Seeing the Arteries Directly
While calcium scoring estimates plaque burden, CT Coronary Angiography is a more detailed assessment of coronary anatomy. The technology visualises both calcified and non-calcified plaques, identifies arterial narrowing and can detect high-risk plaque features that conventional stress testing cannot identify.
Dr. Ezhumalai believes CT Coronary Angiography has become particularly valuable when symptoms, risk factors and treadmill results do not align. Rather than replacing the treadmill test, he says, anatomical imaging complements functional assessment and allows physicians to personalise cardiovascular risk evaluation.
Beyond Blockages
Historically, cardiology focused largely on identifying severe arterial narrowing because these lesions could be treated through angioplasty or bypass surgery. Today, preventive cardiology is shifting towards understanding overall atherosclerotic burden and identifying vulnerable plaques before they rupture.
This approach combines imaging with comprehensive risk assessment using traditional factors such as diabetes, hypertension, smoking, obesity and family history, together with emerging biomarkers including Apolipoprotein B (ApoB) and Lipoprotein(a).
The objective is no longer simply to detect blocked arteries but to identify high-risk individuals early enough to prevent heart attacks altogether.
Personalised Risk Assessment
Despite advances in imaging, Dr. Ezhumalai cautions against replacing one oversimplification with another. No single investigation, he argues, can define cardiovascular risk. Clinical history, family history, blood pressure, diabetes, smoking status, cholesterol profile, metabolic health, inflammatory risk and newer biomarkers should all be considered before deciding on additional imaging.
"When imaging is performed in carefully selected high-risk individuals, it frequently changes management," Dr. Ezhumalai stresses.
Earlier diagnosis may allow timely initiation of statins, more intensive lipid lowering, lifestyle modification, better diabetes control or, when necessary, invasive treatment before a catastrophic event occurs.
"Our objective should never be to detect every plaque," he says. "Our objective should be to identify patients who are most likely to benefit from preventive intervention before a heart attack occurs."
Executive Health Screening
Dr. Ezhumalai believes India's executive health packages also need to evolve. Many continue to follow screening protocols developed decades ago, placing the treadmill test at the centre of cardiovascular evaluation regardless of an individual's underlying risk profile.
Given India's growing burden of premature coronary artery disease, diabetes and metabolic syndrome, he argues that preventive screening should move towards personalised cardiovascular risk assessment rather than standardised investigation packages.
Such assessments would include family history, blood pressure, blood sugar, cholesterol profile, obesity, lifestyle factors, ApoB and Lipoprotein(a) where appropriate, together with selective use of Coronary Artery Calcium scoring or CT Coronary Angiography in patients who are likely to benefit. "The future of preventive screening is precision medicine rather than protocol-driven testing," he says.
The Prevention Gap
Technology alone, however, cannot solve India's cardiovascular crisis. Even as imaging becomes increasingly sophisticated, many patients continue to struggle with modifiable risk factors. Diabetes remains poorly controlled, obesity continues to rise, smoking remains common and physical inactivity has become increasingly prevalent in urban India.
"The most advanced scan in the world cannot compensate for uncontrolled risk factors," Dr. Ezhumalai says. Ultimately, prevention depends on sustained lifestyle modification alongside appropriate medical care.
Cardiac Prevention Vision
For Dr. Babu Ezhumalai, the debate is not about replacing the treadmill test. It is about restoring perspective. The treadmill remains an important investigation when used appropriately. The danger lies in treating any single test as definitive.
Heart disease develops silently over many years before symptoms appear. Effective prevention depends on understanding a person's overall cardiovascular risk through clinical judgement, careful selection of investigations and aggressive management of modifiable risk factors.
He offers one piece of advice to every Indian over the age of 40: "Don't become overly reassured by a single normal test."
Instead, he encourages people to know their blood pressure, blood sugar, cholesterol levels, body weight, waist circumference, smoking status, family history and, where appropriate, their Lipoprotein(a) level, and to discuss their overall cardiovascular risk with their physician.
"The combination of risk-factor assessment, lifestyle modification, appropriate medication and individualised testing - not one isolated investigation - offers the greatest protection."
In a country where heart attacks increasingly affect people in their forties and even thirties, that distinction may prove lifesaving.
